Common spine problems and their treatment a peek behind the curtain

1. Common spine problems and their treatmenta peek behind the curtain Andrew Moulton, MD

2. Goals • 1) Terminology

3. Goals • 2) Common conditions: • Acute neck pain/whiplash • Cervical radiculopathy • Cervical myelopathy • Thoracic disc herniations • Osteoporotic spine fractures • Acute low back pain • Lumbar stenosis • Lumbar radiculopathy/sciatica • 3) Treatment concepts

4. Mechanical Back Pain • Focal aching nature increasing with activity and decreasing with rest • Pain increases as day progresses vs infection/neoplasm (unrelenting) • Degenerative conditions: increased pain in the morning due to muscle/joint stiffness from decreased motion during sleep cycle

5. Discogenic Pain • Increased by: • Axial load • Flexion-extension • Exposure to vibration (ex: operating vibrating machinery/forklift) • Sitting in a car

6. Axial Back Pain • Acute sources of pain • Muscle strains • Ligamentous injury • Chronic sources of pain: • Disk (sinuvertebral nerve, nerve endings) • Facet joints (dorsal primary rami) • Dorsal root ganglia irritation

7. NeurogenicClaudication • Classic symptom of spinal stenosis • Progressive loss of walking ability and duration of standing ability • Pain in lower back, lower legs • Positive “shopping cart sign” • Lumbar radiculopathy

8. Acute Neck Pain • Soft tissue injury or inflammation: muscular or ligamentous strain • Limited motion, no radicular symptoms • Sclerotomal pattern (trapezial regions) • Non-operative care

9. Whiplash • Rear-end collisions • Acute cervical strain with neck pain and stiffness • Pain worse following day • Other presentations: trapezial pain, headaches, dysesthesias, paresthesias, persistent stiffness • Plain XR’s/MRI persistent axial neck pain, true radiculopathy, other neurologic abnormalities

10. Cervical Spine: Radiculopathy • Compression of a single cervical root (cervical disk herniation/DDD) • Sensory dysfunction • Loss of DTR’s • Muscle atrophy • Flacid weakness or paralysis

11. Cervical RadiculopathyBottom Line • >90% patients improve with non-operative care: • Time • Physical Therapy • NSAID’s • Steroid blocks • Weakness, numbness and reflex changes ARE NOT indications for surgery • Most neurologic deficits resolve with non-operative therapy. • Many patients are not aware that reflex, sensory and motor deficits can persist despite surgery.

12. Cervical Myelopathy • One of the most commonly missed diagnosis • “Absolute” surgical indication • Etiology: cervical spinal stenosis (spondylotic vs congenital vs acute)

13. Cervical Myelopathy • Presentation: • Unexplained extremity weakness, “heaviness” • Gait abnormality, loss of balance, falls – loss of proprioception • Loss of coordination • Dexterity loss, “clumsiness” • Neck pain, arm pain NOT common • Signs: Hoffman’s, hyper-reflexic DTR’s

14. Cervical Myelopathy • Surgery: • Anterior diskectomy vs corpectomy and fusion • Posterior decompression • Laminectomy • Laminoplasty • Decompression and fusion • Surgical intervention usually associated with improved neurologic outcome

15. Cervical Spine Non-op Treatment • Goals: help control patient’s pain and limit disturbance of his/her everyday limit • Pain cycle: pain -> immobilization -> deconditionning/muscle atrophy/joint adhesions -> pain ….

16. Cervical Spine Non-op Treatment • Modalities: • - rest: >2 days associated with loss of strength, flexibility, and aerobic fitness • - soft c-collar: keep neck in some flexion (extension can be painful), wear at night (protect discs from overload due to poor posture) – ONLY for a few days • - passive modalities, ice, heat • - traction: no proven benefit except in acute herniated discs with arm pain (keep neck in some flexion

17. Cervical Spine Non-op Treatment • Isometric exercises – prevent muscular atrophy in patients with poor mobility HOWEVER it can lead to disc loading • Flexibility exercises – AVOID passive motion as patients may not be able to protect themselves from injury • Aerobic conditioning – more for chronically debilitated patient severely deconditioned – LOW IMPACT (exercise bike, treadmill walking, elliptical)

18. Cervical Spine Non-op Treatment • Resistive Exercises: • Early supervision • Start with warm-up (aerobic exercise) • Proper alignment of the head in relationship to the trunk w/ abdominal exercises • Special attention to shoulder girdle and neck musculature • Initially: low weights, high repetitions - endurance

19. Cervical Spine Non-op Treatment • For cervical disc disease patients emphasis on scapular stabilization muscles (trapezius, deltoid, latissimus dorsi, rhomboids) • Shrugs, dumbbell rows, upright rows, pull downs to the chin (not to the back of head – minimize forced flexion), front and lateral dumbbell raises

20. Cervical Manipulation • Contraindications: • Vertebral fracture/dislocation • Infection • Malignancy • Spondylolisthesis • Myelopathy • Vertebral hypermobility • Osteoporosis • Severe diabetes melitus • Anticoagulation therapy • Spinal nerve root compromise

21. Cervical Spine - Surgery • Posterior Cervical Decompression Fusion – risk of muscle atrophy, kyphotic deformity • 0-4/6 weeks: control pain/ inflamation (ice, electrical stim, massage) • Active Modalities: cardiovascular, neck/upper back muscle stabilizers • Body mechanics: keep neck in stable positions • 3-6 months (after fusion): no restrictions

22. Cervical Spine - Surgery • Anterior Cervical Discectomy and Fusion • 0-4/6 weeks: body mechanics, restrict motion • 3 months (after fusion): full unrestricted activities

23. Cervical Spine - Surgery • Laminoplasty – decompressive procedure without fusion • PT: more aggressive ROM, strenthening

24. Cervical Spine - Surgery • CONCEPTS: • With fusion patients: body mechanics, preserve ROM, muscle conditionning until fully fused then full unrestricted activities (3-6 months) • With non-fusion patients (decompression, laminoplasty): more aggressive ROM, active modalities once soft tissue healed then full unrestricted activities (4-6 weeks)

25. Thoracic Disc Herniation • Symptoms: axial pain (nerve fibers annulus fibrosus/PLL), radiculopathy (pain in chest wall, burning sensation, numbness), thoracic myelopathy • Worse with Valsalva maneuver • Imaging: XR, MRI, CT myelogram (if MRI contraindicated)

26. Thoracic Disc Herniation • Frequency: 0.15-4.0% of all disk herniations (incidental finding in 20% cases) • Most commonly at T10-L1

27. Thoracic Disc Herniation • Treatment: • Nonsurgical: no significant neurologic dysfunction or myelopathy • Bed rest, mobilization • Meds: oral corticosteroids, NSAID’s, opiates • Orthosis • PT • Injection • Surgical - fusion

28. Thoracic Disc Herniation • Physical Therapy: • Maintain ROM/strengthening / body mechanics • Minimize increased disc pressure/axial loads: • Decrease full flexion • Minimize heavy lifting • Use pain as a limiting factor • Posterior Spinal Fusion: • Body mechanics, ROM, strengthening 6-8 weeks postop • Full physical activities once healing is evident at 3-6 months

29. Osteoporotic Compression Fractures • 2/3 undetected and pain free • 1/3 chronically painful • None ever spontaneously regain height or sagittal alignment

30. Osteoporotic Compression Fractures: Treatment Vertebroplasty or Kyphoplasty • Both are very effective in treating pain, ~90% • Both have a very low complication rate, <1% • Kyphoplasty has the potential to restore anatomy

31. Impact of Osteoporotic Compression Fractures Spinal deformity correlates with • Impaired gait, poor balance (Gold 1996, Sinaki 2004) • Disability, reduced quality of life(Leidig-Bruckner 1997) • Reduced lung function(Leech 1990, Culham 1994, Schlaich 1998) • Early satiety, gastric distress(Gold 1996) • Future facture risk(Kado 2003) • Excess mortality(Kado 1998, Kado 2004, Huang 2005)

32. Osteoporotic Compresion Fractures – Non-op Treatment • Non-operative: • Body mechanics – minimize kyphosis • Strengthening, cardiovascular • Postoperative (kyphoplasty) care: • FULL unrestricted activities – no fusion and only minimal soft tissue dissection • Emphasize extension exercises, ROM

33. Lumbar SpineAcute Low Back Pain • Second most frequent request for medical attention (after URI) • 80% adult population: at least 1 episode • Most common cause - soft tissue structures: • Muscular strain, ligamentous sprain from overuse or acute injury • Acute stretching of posterior longitudinal ligament or anulus fibrosus (disk herniation)

34. Lumbar Spine: Low Back Pain • Muscle strain, ligament sprain • Discogenic pain, annular tears • Segmental instability • Facet joint arthropathy • Spondylolisthesis • Spinal stenosis

35. Acute Low Back Pain • Acute disk herniation: initial LBP (both sides, muscle spasm, pain referred to buttocks) followed by radicular symptoms after several days • Facet syndrome: inflammation or injury of isolated facet – localized ipsilateral pain • Aggravation of lumbar spondylosis: in patients with chronic LBP (minor injury)

36. Chronic Low Back Pain • Degenerative conditions • Disk dehydration (“black disk disease”) • Disk height loss -> osteophyte formation, facet arthrosis and ligamentum flavum hypertrophy • Typically no leg symptoms (if no stenosis) • Typical patient: obese, limited muscle mass, poor anaerobic conditioning, smoke, medical comorbidities

37. Surgical Treatment of Back Pain • Fusion • Artificial Disc Pain relief success rate: 65%

38. Lumbar Radiculopathy - Sciatica • Acute onset with disk herniation in 20-30’s - see prodrome of low back pain • Typically unilateral • Associated paresthesias • Possible associated weakness • Symptoms worse with increased intrathecal pressure (coughing, sneezing, and straining with BM), sitting (vs. walking) • Buttock pain: radiculopathy vs. facet joint pathology • Bilateral radiculopathy vs cauda equina

39. Spinal Stenosis • Normal progression of aging • Most people do not develop symptoms • Most patients do not require surgery

40. Spinal Stenosis • Presentation: neurogenic claudication • It is a disease of exertion • Physical exam is most often normal • Weakness and numbness is not typical

41. Spinal Stenosis: Classic Presentation • Buttock and leg pain when walking or standing • Starts proximally and moves distally • Relieved by sitting or bending over • Normal exam

42. Lumbar Stenosis • Surgical options: • Continue to evolve • Laminectomy • Minimally invasive decompression • Interspinous Devices (X-Stop)

43. Lumbar Spine – Treatment Concepts • Non-operative patients: • Acute low back pain: initial emphasis on passive then switch to active modalities • Chronic low back pain: active modalities, ROM • Disc Herniation: minimize axial loading, body mechanics • Post-operative patients: • Non-fusion: active modalities • Fusion: • 0-4/6 weeks: soft tissue work, body mechanics, • 3-6 months: return to full activities

44. Thank You!